|
||||||||||||||||||||
|
||||||||||||||||||||
| ||||||||||||||||||||
| ||||||||||||||||||||
| ||||||||||||||||||||
1 | AN ACT concerning insurance.
| |||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| |||||||||||||||||||
3 | represented in the General Assembly:
| |||||||||||||||||||
4 | Section 5. The Managed Care Reform and Patient Rights Act | |||||||||||||||||||
5 | is amended by changing Section 15 as follows:
| |||||||||||||||||||
6 | (215 ILCS 134/15)
| |||||||||||||||||||
7 | Sec. 15. Provision of information.
| |||||||||||||||||||
8 | (a) A health care plan shall provide annually to enrollees | |||||||||||||||||||
9 | and prospective
enrollees, upon request, a complete list of | |||||||||||||||||||
10 | participating health care providers
in the
health care plan's | |||||||||||||||||||
11 | service area and a description of the following terms of
| |||||||||||||||||||
12 | coverage:
| |||||||||||||||||||
13 | (1) the service area;
| |||||||||||||||||||
14 | (2) the covered benefits and services with all | |||||||||||||||||||
15 | exclusions, exceptions, and
limitations;
| |||||||||||||||||||
16 | (3) the pre-certification and other utilization review | |||||||||||||||||||
17 | procedures
and requirements;
| |||||||||||||||||||
18 | (4) a description of the process for the selection of a | |||||||||||||||||||
19 | primary care
physician,
any limitation on access to | |||||||||||||||||||
20 | specialists, and the plan's standing referral
policy;
| |||||||||||||||||||
21 | (5) the emergency coverage and benefits, including any | |||||||||||||||||||
22 | restrictions on
emergency
care services;
| |||||||||||||||||||
23 | (6) the out-of-area coverage and benefits, if any;
| |||||||||||||||||||
24 | (7) the enrollee's financial responsibility for | |||||||||||||||||||
25 | copayments, deductibles,
premiums, and any other | |||||||||||||||||||
26 | out-of-pocket expenses;
| |||||||||||||||||||
27 | (8) the provisions for continuity of treatment in the | |||||||||||||||||||
28 | event a health care
provider's
participation terminates | |||||||||||||||||||
29 | during the course of an enrollee's treatment by that
| |||||||||||||||||||
30 | provider;
| |||||||||||||||||||
31 | (9) the appeals process, forms, and time frames for | |||||||||||||||||||
32 | health care services
appeals, complaints, and external |
| |||||||
| |||||||
1 | independent reviews, administrative
complaints,
and | ||||||
2 | utilization review complaints, including a phone
number
to | ||||||
3 | call to receive more information from the health care plan | ||||||
4 | concerning the
appeals process; and
| ||||||
5 | (10) a statement of all basic health care services and | ||||||
6 | all specific
benefits and
services mandated to be provided | ||||||
7 | to enrollees by any State law or
administrative
rule.
| ||||||
8 | In the event of an inconsistency between any separate | ||||||
9 | written disclosure
statement and the enrollee contract or | ||||||
10 | certificate, the terms of the enrollee
contract or certificate | ||||||
11 | shall control.
| ||||||
12 | (b) Upon written request, a health care plan shall provide | ||||||
13 | to enrollees a
description of the financial relationships | ||||||
14 | between the health care plan and any
health care provider
and, | ||||||
15 | if requested, the percentage
of copayments, deductibles, and | ||||||
16 | total premiums spent on healthcare related
expenses and the | ||||||
17 | percentage of
copayments, deductibles, and total premiums | ||||||
18 | spent on other expenses, including
administrative expenses,
| ||||||
19 | except that no health care plan shall be required to disclose | ||||||
20 | specific provider
reimbursement.
| ||||||
21 | (c) A participating health care provider shall provide all | ||||||
22 | of the
following, where applicable, to enrollees upon request:
| ||||||
23 | (1) Information related to the health care provider's | ||||||
24 | educational
background,
experience, training, specialty, | ||||||
25 | and board certification, if applicable.
| ||||||
26 | (2) The names of licensed facilities on the provider | ||||||
27 | panel where
the health
care provider presently has | ||||||
28 | privileges for the treatment, illness, or
procedure
that is | ||||||
29 | the subject of the request.
| ||||||
30 | (3) Information regarding the health care provider's | ||||||
31 | participation
in
continuing education programs and | ||||||
32 | compliance with any licensure,
certification, or | ||||||
33 | registration requirements, if applicable.
| ||||||
34 | (d) A health care plan shall provide the information | ||||||
35 | required to be
disclosed under this Act upon enrollment and | ||||||
36 | annually thereafter in a legible
and understandable format. The |
| |||||||
| |||||||
1 | Department
shall promulgate rules to establish the format | ||||||
2 | based, to the extent
practical,
on
the standards developed for | ||||||
3 | supplemental insurance coverage under Title XVIII
of
the | ||||||
4 | federal Social Security Act as a guide, so that a person can | ||||||
5 | compare the
attributes of the various health care plans.
| ||||||
6 | (e) The written disclosure requirements of this Section may | ||||||
7 | be met by
disclosure to one enrollee in a household.
| ||||||
8 | (f) An enrollee entitled to the information set forth in | ||||||
9 | subsection (a) of this Section may choose to waive his or her | ||||||
10 | rights to receive such information in a printed form from his | ||||||
11 | or her health care plan so long as such information is readily | ||||||
12 | accessible on the health care plan's Internet site. An enrollee | ||||||
13 | may revoke such a waiver at any time by notifying the health | ||||||
14 | care plan by phone or in writing. Any enrollee who does not | ||||||
15 | execute such a waiver and prospective enrollees shall have the | ||||||
16 | information set forth in subsection (a) of this Section | ||||||
17 | provided in printed form.
| ||||||
18 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
19 | Section 99. Effective date. This Act takes effect upon | ||||||
20 | becoming law.
|